title: Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules.
abstract: BACKGROUND
  The ACGME-released revisions to the 2003 duty hour standards.
  
  
  OBJECTIVE
  To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.
  
  
  METHODS
  Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.
  
  
  METHODS
  We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.
  
  
  METHODS
  One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.
  
  
  RESULTS
  Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.
  
  
  CONCLUSIONS
  Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.
  
  
  CONCLUSIONS
  Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.
authors.affiliation: Department of Medicine, Milwaukee VAMC/ Medical College of Wisconsin, Milwaukee, WI 53295, USA. kfletche@mcw.edu
authors.forename: Kathlyn E
authors.initials: KE
authors.lastname: Fletcher
authors.forename: Darcy A
authors.initials: DA
authors.lastname: Reed
authors.forename: Vineet M
authors.initials: VM
authors.lastname: Arora
mesh_terms: D001291:Attitude of Health Personnel; D006801:Humans; D007396:Internship and Residency / Q000331:legislation & jurisprudence* / Q000639:trends; D061214:Patient Safety / Q000331:legislation & jurisprudence*; D010549:Personal Satisfaction; D010561:Personnel Staffing and Scheduling / Q000331:legislation & jurisprudence* / Q000639:trends; D012189:Retrospective Studies; D014940:Work Schedule Tolerance / Q000523:psychology*; D016526:Workload / Q000331:legislation & jurisprudence / Q000523:psychology